How to Fill Out the California DS 2200 Medicaid Waiver Form

The California DS 2200 Medicaid Waiver form is a one-page document that records which living arrangement a regional center consumer chooses under the state’s Home and Community-Based Services (HCBS) waiver. You complete it with your service coordinator, usually at an Individual Program Plan meeting, by checking one of three options — in-home living, a community care residential facility, or a long-term health care facility — and signing to confirm the choice was informed and voluntary. A signed copy must be on file before the regional center can bill federal Medicaid funding for waiver services.¹

What the Form Documents

The full title is the “Medicaid Waiver Consumer Choice of Services/Living Arrangement Statement.” Federal HCBS rules require every state operating a waiver to give each participant an informed choice between community-based services and institutional care, and to document that choice in writing. The DS 2200 is how California satisfies that requirement for its developmental disabilities waiver.²

Before you sign, the regional center must tell you about all feasible service alternatives available under the waiver. The form then records your selection. Choosing community-based care is what triggers HCBS waiver funding for your services; choosing institutional placement means services are funded through a different Medicaid mechanism.³

One boundary worth naming: the DS 2200 is not an application for regional center services. It is only completed by people who are already regional center consumers or have just been found eligible. If you are trying to get in the door for the first time, that happens through a separate intake and assessment process with the regional center serving your county.

When You Sign It

The form is not routine paperwork you sign every year. It comes into play at specific moments in a consumer’s relationship with the waiver:

When the regional center first determines you are eligible for HCBS waiver-funded services.
When someone who previously left the waiver program becomes eligible again.
When a consumer turns 18 and must make or reaffirm the living arrangement choice as an adult.

At each of these points a new signed DS 2200 must be on file before the regional center can draw federal Medicaid dollars for that consumer.¹

Filling Out the Form Field by Field

The DS 2200 is short. It has four identification fields at the top, a choice section in the middle, and a signature block at the bottom. Most people complete it during an IPP meeting. The English version is on the DDS website, and a Spanish version (DS 2200 SP) is posted separately.⁴

The Identification Fields

The top of the form asks for four things: the consumer’s full name, the date the choice is being made, the consumer’s date of birth, and the consumer’s UCI (Unique Consumer Identifier). The UCI is the identification number the regional center assigned when you entered its system; your service coordinator can give it to you if you do not have it handy. The form does not ask for a Social Security number, proof of residency, or biographical detail.²

The Living Arrangement Choice

The middle of the form presents three options. You check the box next to the one you prefer. The regional center must explain each option before you sign.

In-home living arrangement. You live in your own home or with family and receive community-based supports such as supported living services, day programs, respite, and other waiver-funded services.
Community care residential facility. A licensed group home or adult residential facility in the community, staffed to provide varying levels of personal care and supervision.
Long-term health care facility. An institutional setting: an ICF/DD (15 or more residents with 24-hour nursing), an ICF/DD-H (typically six or fewer residents with intermittent nursing needs), or an ICF/DD-N (for residents needing more regular medical monitoring such as tube feedings).

Most consumers select one of the first two. The community-based options are what the HCBS waiver was designed to fund, and they align with California’s policy under the Lanterman Act of supporting people in the community rather than in institutions.³

The Signature Block

Who signs depends on the consumer’s age and legal status. An adult consumer who manages their own affairs signs the form themselves. For a minor, a parent or legal guardian signs. If the consumer has a conservator, the conservator signs. The signature must be consistent with signatures on other consent and release forms in the consumer’s regional center file.²

There is also a line for the person who explained the service alternatives, typically the service coordinator. Both signatures and dates need to be filled in. An unsigned or undated form cannot serve as valid documentation of informed choice, which means the regional center cannot bill the waiver for that consumer’s services until it is corrected.

Understanding What You Are Choosing

The choice you mark shapes what services you receive and how they are paid for, so it is worth understanding what each option looks like in practice.

In-Home and Community Living

This is the most common selection and the one California’s system is built to support. You might live independently with supported living services, live with family members who receive respite and other supports, or live in a smaller community setting. The HCBS waiver funds services like supported employment, day programs, transportation, personal assistance, and behavior intervention, all delivered in community settings.³

Community Care Residential Facility

These are licensed group homes and adult residential facilities. Staffing levels and the intensity of personal care and supervision vary by facility. Services in this setting are also waiver-funded when you have selected community-based care on the DS 2200.

Long-Term Health Care Facility

The institutional option provides 24-hour care in a licensed health facility. An ICF/DD is the largest type, with 15 or more beds and registered nursing staff on site. An ICF/DD-H is smaller, typically six or fewer residents, with intermittent nursing supervision. An ICF/DD-N serves people with chronic medical conditions requiring more intensive nursing such as tube feedings or regular suctioning.

Choosing institutional care does not end your relationship with the regional center. The center continues to coordinate your services and conduct IPP reviews. What changes is the funding source: waiver dollars follow the community-based options, not the institutional one.

If Your Choice Changes Later

The living arrangement you record on the DS 2200 is not permanent. If your needs or preferences change, you can request an IPP meeting and update your choice at any time, and a new DS 2200 is completed to document the change. An in-person meeting with your service coordinator has to happen at least every 12 months in any case, and you can request one sooner whenever your circumstances shift.⁵

Where to Get a Blank Form

In practice you will rarely need to hunt down a blank DS 2200. Your service coordinator brings it to the IPP meeting or provides it when you first become eligible for waiver services. If you want to review it beforehand, the English version is posted as a PDF on the DDS website, and the Spanish version (DS 2200 SP) is available on a separate page.² To find the regional center serving your area, use the DDS county lookup tool or call the Department of Developmental Services at (916) 654-1958.⁶

1
California Department of Developmental Services. HCBS Waiver Primer and Policy Manual
2
California Department of Developmental Services. DS 2200 Medicaid Waiver Consumer Choice of Services/Living Arrangement Statement
3
CA Department of Developmental Services. Home and Community-Based Services Programs
4
Department of Developmental Services. DS 2200 SP – Medicaid Waiver Choice of Services/Living Arrangement
5
CA Department of Developmental Services. Individual Program Planning
6
CA Department of Developmental Services. Regional Center Lookup